Failure to Ensure Functioning Bed Alarm Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a previously implemented fall intervention, specifically a silent bed alarm, was in place and functioning for a resident identified as high risk for falls. The resident, who had diagnoses including moderate dementia, chronic kidney disease, COPD, generalized anxiety disorder, and osteoporosis, was assessed as a high fall risk and had a care plan that included the use of a staff-alerting bed alarm as a fall prevention measure. Despite this, the bed alarm did not activate when the resident attempted to self-transfer and subsequently fell, resulting in significant injuries including a left forehead laceration, a left frontal scalp hematoma, multiple skin tears, and severe pain. The facility's policies required that safety measures be included in the care plan from admission, revised after any fall, and that the cause of any fall be determined with measures taken to prevent recurrence. The silent bed alarm policy specified that alarms should be checked for proper function each shift, including testing the alarm to ensure it activated the call light and CNA phone. However, staff interviews revealed that the bed alarm was only visually checked for a green light, and not physically tested to confirm it would sound or alert staff when activated. On the night of the incident, the alarm remained green but did not alert staff when the resident got out of bed or fell, and only activated later when the resident was moved by paramedics. Documentation showed that the resident was found on the floor with a large amount of blood from a head laceration and multiple skin tears. The incident was unwitnessed, and the malfunctioning alarm was identified as the root cause of the failure to prevent the fall. The resident was transferred to the emergency room for treatment of her injuries, which included a large open wound on the forehead, skin tears on the left shoulder, lower left leg, and right forearm, and was noted to be in severe pain upon arrival at the hospital. The facility's investigation confirmed that the bed alarm was not functioning as intended at the time of the fall.